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JUDITH T. TERRY s : i. Town Hall, 53095 Main Road
3•T :':` '`' P.O. Box 1179
TOWN CLERK ® Southold, New York 11971
REGISTRAR QF VITAL STATISTICS Q
MARRIAGE OFFICER � Fax (516) 765-1823
®�iLi�� �� Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1930-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MACOMBER, WILLIAM E.
Mailing Address 1 28 WILMARTH AVENUE
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 28 WILMARTH AVENUE
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner T�';S�e 'fi+!i .: 3e: _ 7.k11547
Tax Map No. section 41 .00 block 1 lot 9.000
Cross Street MAIN STREET
Date Of Last Pump Out 0/00/00
Issue Date: 6/24/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK 'c��FFO(,� " p
Town of Southold �� w CQ ' , Application No.19 3
Judith T. Terry, Town Clerk ��? � .; •
Town Hall, 53095 Main Road �s�� ` t
^, a. I $10.00 - Residential
p. O. Box 1179 �. < h�i � $25.00 - Non-Residential
Southold, New York 11971 O : 0-,e�
Telephone 441,•'11.'
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for. - ,
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 3 I 47
-OWNER NAME: IA__) , q A. 41 bC� t—IIQ�I�
OWNER MAILING ADDRESS: g L3 C r4
— -- - OWNER-PROPER-TY ADDRESS:- 5- ._ — -
OWNER TELEPHONE NUMBER: e f 77, �2 v
TAX MAP NO. : Section" tilt Block f Lot
CROSS STREET: ti A CT
TYPE OF SYSTEM: Septic'Tank- • New \ Existing
Cesspool New Existing
Residential 1-1 Non-Residential
DATE OF PREVIOUS PUMP-OUT:T) , "" �.�:e ,�(� �,,2, - 7 Lr 0„,
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest- road.)
/
)14afr4e -
Signature of Applicant
RECEIVED BY: -- - - -
- -. •TownClerk's Office
DATE:-
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